DS Rose, Inc.
New Customer Questionnaire
Company Name:
First Name:
*
Last Name:
Phone:
*
Email:
New Unit Questionnaire
What type of chassis is this unit:
*
Select Unit Type
407 CHEMICAL CARBON STEEL - UNLINED
Automobile
Bobcat
Box Truck
Box Truck with Liftgate
Box Truck with Refrigeration Unit
Bulk Truck
Bus
Chassis
Container
Container Chassis
Dolly
Dry Bulk Tanker
Dump Truck
Flatbed Trailer
Fork Lift
Generator / APU
Grease Tote
IBC Tote
ISO Container
Light Duty
Medium Duty
Motorhome
Sprinter
Tanker
Tanker: 304 CHEMICAL STAINLESS STEEL
Tanker: 306 PETROLEUM ALUM
Tanker: 307 ALUMINUM
Tanker: 307 CHEMICAL STAINLESS STEEL
Tanker: 312 CHEMICAL CARBON STEEL - LINED
Tanker: 312 CHEMICAL STAINLESS STEEL
Tanker: 331 CHEMICAL STAINLESS STEEL
Tanker: 406 PETROLEUM ALUM
Tanker: 407 CHEMICAL ALUMINUM
Tanker: 407 CHEMICAL STAINLESS STEEL
Tanker: 407 CHEMICAL STAINLESS STEEL - Lined
Tanker: 407 VACUUM STAINLESS STEEL
Tanker: 412 CHEMICAL CARBON STEEL
Tanker: 412 CHEMICAL CARBON STEEL - LINED
Tanker: 412 CHEMICAL STAINLESS STEEL
Tanker: 412 VACUUM STAINLESS STEEL
Tanker: 412 VACUUM STAINLESS STEEL (FULL OPEN)
Tanker: FRP Tanker
Tanker: NON-CODE ALUM
Tanker: NON-CODE MILD STEEL
Tanker: NON-CODE STAINLESS STEEL
Tractor
Trailer (default)
VIN
:
Year:
Make:
Model:
Unit Number:
Unit Nickname:
License Plate:
Service Request Questionnaire
Complaints / Problems / Requests
Describe first complaint, problem, or request:
*
How urgent is this:
*
Schedule as soon as possible
Schedule repair today
Emergency - Get this fixed right away
Remember for the next visit
Add another
Scheduling & Authorization
When will the unit be available for repairs:
Now
The unit MUST be accessed at the above date and time.
When would you like the unit back:
Return ASAP
How would you like us to access the unit:
*
Select Access Method
No preference, just get it done!
Customer will bring unit to the shop
Shop will service unit on-site
Shop will pick up unit and bring to the shop
Shop will tow unit
Where will this unit be located for access:
*
Select Address
Temporary Address (please put address in the Helpful Notes below)
Add A New Address
Street Address:
*
Street Address 2:
City:
*
Country:
*
United States
Canada
Australia
Antigua and Barbuda
Argentina
Aruba
Bahamas
Barbados
Belize
Bolivia
Brazil
British Virgin Islands
Cayman Islands
Chile
China
Colombia
Costa Rica
Curaçao (Netherlands)
Dominica
Dominican Republic
Ecuador
Germany
Greece
Guyana
Haiti
Hong Kong
Italy
Jamaica
Mexico
New Zealand
Norway
Panama
Paraguay
Peru
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Saudi Arabia
Sint Maarten
South Korea
Suriname
Trinidad and Tobago
Turks and Caicos
Uruguay
US Virgin Islands
Venezuela
West Indies
State:
*
Postal Code:
*
Address Name:
*
Save
Cancel
Would you like the shop to deliver the unit:
*
No - Customer will pick up unit from shop
Yes - Shop will return unit to customer
Where would you like this unit delivered:
*
Select Address
Temporary Address (please put address in the Helpful Notes below)
Add A New Address
Street Address:
*
Street Address 2:
City:
*
Country:
*
United States
Canada
Australia
Antigua and Barbuda
Argentina
Aruba
Bahamas
Barbados
Belize
Bolivia
Brazil
British Virgin Islands
Cayman Islands
Chile
China
Colombia
Costa Rica
Curaçao (Netherlands)
Dominica
Dominican Republic
Ecuador
Germany
Greece
Guyana
Haiti
Hong Kong
Italy
Jamaica
Mexico
New Zealand
Norway
Panama
Paraguay
Peru
Puerto Rico
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Saudi Arabia
Sint Maarten
South Korea
Suriname
Trinidad and Tobago
Turks and Caicos
Uruguay
US Virgin Islands
Venezuela
West Indies
State:
*
Postal Code:
*
Address Name:
*
Save
Cancel
Authorization Number:
PO Number:
Notes and Instructions For Shop:
Step 4: Additional Information:
Unit Identifier:
Driver Name / #:
Engine:
Reference #:
Payment Method:
Select Payment Method
ACH
American Express
Cash
Check
Cheque
Comchek
Credit
Credit Card
Discover
E-Check
EFS
EFT
Fleet One
Internal Payment
MasterCard
National Account Credit
T -Check
Visa
How did you hear about us (e.g. shop website):
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